Enrollment Agreement

Enrollment Agreement

Thank you for your interest in enrolling with Finance Your Care. Please complete the information below so we can get your Practice set up, and we can identify the lenders in our portfolio that will be the best fit for your Practice. If you have any questions, please call (844) 995-4657.
What is the legal name of your Practice*
Make sure you include (LLC, PA, Inc)
What is your Practice specialty (i.e. Chiropractic, Plastic Surgery, etc.)*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number*
Format: (000) 000-0000.
What is the Practice email*
Who is the contact person we should call or email?*

First NameLast Name
Contact person's phone number if different than above
Please enter a valid phone number.Format: (000) 000-0000.
Contact person's email if different than above
example@example.com
What is your Practice website?*
What is the Doctor's or Owner's name*

First NameLast Name
How many loans do you close every month?*
What is your average loan amount?*
Please list the patient financing companies you are currently using.
Enrollment Options
Fully Automated: This is the format that most Practices use. With this enrollment option, you (or the Applicant) will process the application through our automated system from start to close. The process takes about five minutes.

Finance Manager Assisted: This enrollment format was designed for Providers that really do not want to be involved in the loan process. With this format, you (or the Applicant) will submit the application and get a pre-qualification only. At that point, one of our Finance Managers will take over the processing and get the request submitted to the lenders. The benefit to this format is it will free up your staff's time and often leads to more approvals. The negative is that the turn-around time for a final decision may be up to one business day.
Which type of enrollment plan do you prefer?*
Please review the following lender program options, and let us know which of these programs you would like to enroll to use. NOTE: These are third party lender programs.
YesNoI would need to learn more.
YesNoI would need to learn more.
YesNoI would need to learn more.
YesNoI would need to learn more.
YesNoI would need to learn more.
Fee Disclosure:

FEE TO YOUR PRACTICE: Our goal is to provide our technology platform to your Practice with no direct fee. However, we do require that each Practice closes two transactions a month. If you do not close two transactions in a month, we will charge you a $375 fee for that month. APPLICANT USER FEE: We will charge each of your Applicants a fee of $187.50 if they get approved and they accept a loan offer. The fee can be added to the loan amount, and it will be financed. Or, we can collect a credit or debit card directly from the Applicant during the application process and charge the card once the approval has been completed. NOTE: If the fee is financed, it will be paid to your Practice when you are funded. In those cases, we will send you an invoice and charge the fee back to your office after we verify you have been paid. Please respond to the next two questions.
YesNo, cancel my enrollment
Yes, collect the fee directly from the Applicant.No, invoice my business for each funding fee.
Set Up Deposit:

As a part of your enrollment, we charge a one-time set up deposit fee of $375. This fee is charged to prevent a Practice from signing up "just because it is free". This fee will be credited back to you after six months using the platform. PLEASE NOTE: We will send you an invoice for this deposit after we receive this form back. We will not start your onboarding until the deposit is paid.
YesNo, cancel my enrollment
Enrollment Term:

This agreement will be based on a month-to-month agreement that can be cancelled by either party with a 30 days' notice. However, if you have an outstanding balance at time of cancellation, you will be required to pay that balance within 30 days.
What happens next:

Once we receive your enrollment request, we will contact your Practice and discuss the lender programs you are interested in enrolling to use. Then we will send you a check list of the documents each lender will require you to provide for their enrollment, and another form like this that you can use to upload those documents. As soon as we get those documents back, we will start your enrollments with the lenders. Most of the lenders will take between 7 and 10 business days to approve your practice and set you up. But don't worry, we will be here to support the process and push it along the way.
Thank you for submitting your enrollment request. If you have any questions or concerns, please call (844) 995-4657.
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Enrollment Agreement

Enrollment Options

Fee Disclosure:

Set Up Deposit:

Enrollment Term:

What happens next: